A client is brought to the emergency department (ED) by fami...

A client is brought to the emergency department (ED) by family members who tell the triage nurse that the client doesn't recognize them. The client is diagnosed with a neurologic deficit. What other condition(s) is considered a neurologic deficit? Select all that apply.

A. Impaired speech
B. Abnormal bladder elimination
C. Muscle strength
D. Normal gait
E. Paralysis

Correct Answer: A,B,E

Rationale: A neurologic deficit a condition in which one or more functions of the central and peripheral nervous systems are decreased, impaired, or absent. Examples include paralysis, muscle weakness, impaired speech, inability to recognize objects, abnormal gait or difficulty walking, impaired memory, impaired swallowing, or abnormal bowel and bladder elimination.

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A nurse has just received a new client and is preparing to perform a neurologic assessment. Which of the following assessment tools should the nurse use?

A. Cutaneous triggering
B. Mini-Mental Status Examination
C. Cred?©'s maneuver
D. Mechanical lift

Correct Answer: B

Rationale: The nurse uses assessment tools such as the Mini-Mental Status Examination to perform the neurologic assessment. Cutaneous triggering and Cred?©'s maneuver are techniques used in implanting a bladder training program. A mechanical lift is used to transfer a client to and from the bed, wheelchair, or shower.

A nurse is caring for a client with slight expressive aphasia. Which nursing technique(s) facilitates communication with the client? Select all that apply.

A. Offer a communication board.
B. Encourage exercises such as whistling.
C. Allow time for the client to respond to questions.
D. Guess words the client has difficulty saying and confirm understanding with the client.
E. Provide sensory aids.

Correct Answer: A,C,D

Rationale: The nurse should offer a communication board to the client, allow time for the client to respond to questions, and guess words the client has difficulty saying and confirm understanding with the client. Encouraging exercises such as whistling are appropriate for a client with dysarthria, not expressive aphasia. Providing sensory aids such as glasses is a technique appropriate for a client with receptive aphasia, not expressive aphasia.

The nurse is performing discharge teaching for a female client who was hospitalized after a spinal cord injury that resulted in motor paralysis. Which of the following prescription classifications, used prior to hospitalization, is most important to review with the client before discharge?

A. An oral contraceptive
B. A nonsteroidal anti-inflammatory
C. An analgesic
D. An antihistamine

Correct Answer: A

Rationale: Motor paralysis does not affect ovulation. It is important for the nurse to review the need for continued contraceptive use with the client if a pregnancy is still undesired. A nonsteroidal anti-inflammatory, an analgesic, and an antihistamine used prior to the spinal cord injury may be reviewed prior to discharge but are lower priority.

In which of the following disease processes is the nurse most likely to care for a client in the chronic phase of a neurologic disease?

A. Transient ischemic attack (TIA)
B. Malignant brain tumor
C. Alzheimer disease
D. Pneumonia

Correct Answer: C

Rationale: Clients with Alzheimer disease are often admitted to the hospital for treatment of complications. Sometimes, when their disease process progresses, they are also admitted to a skilled nursing facility. A transient ischemic attack causes transient symptoms or minor neurologic deficits. A malignant brain tumor typically causes debilitating symptoms and spreads due to the malignant nature causing death. Pneumonia is a complication of neurologic deficits, but itself is not a neurologic deficit. Pneumonia can be resolved with antibiotics depending on the status of the client.

A client is brought to the emergency department in a confused state, with slurred speech, characteristics of a headache, and right facial droop. The vital signs reveal a blood pressure of 170/88 mm Hg, pulse of 92 beats/minute, and respirations at 24 breaths/minute. On which bodily system does the nurse focus the nursing assessment?

A. Cardiovascular system
B. Respiratory system
C. Endocrine system
D. Neurovascular system

Correct Answer: D

Rationale: The client is exhibiting signs of an evolving cerebrovascular accident, possibly hemorrhagic in nature, with neurologic complications. Nursing assessment will focus on the neurovascular system assessing level of consciousness, hand grasps, communication deficits, etc. Continual cardiovascular assessment is important but not the main focus of assessment. Respiratory compromise is not noted as a concern. The symptoms exhibited are not from an endocrine dysfunction.